MINIMUM VIEWS FOR A POCUS EXAM

POCUS MINIMUM VIEWS .pdf

It is always important to get the right images to prove that what you have seen is correct. In order to standardise the images which are saved and to make it easier for other doctors to interpret your findings, each POCUS examination should have a minimum set of images which should be saved in all instances. If there is pathology, it is helpful to save more images from different angles/ positions (always label these) and even clips. 

Below are the common POCUS examination with associated slide shows of standard images for each.

EFAST 

The role of EFAST in trauma has changed rapidly in the last 2 decades. EFAST can never be as accurate as CT. However, it is still very important in the initial assessment. Integrated into the primary survey of the trauma patient, it enables rapid decision making and management at the bedside prior to other imaging: diagnosis and treatment of large pneumo/haemothoraces, immediate theatre for the deteriorating patient with intraperitoneal fluid, ED thoracotomy for pericardial fluid. 

MACHINE AND PATIENT SETTINGS

  • Curvilinear transducer
  • Abdominal setting
  • Patient supine 

MINIMUM VIEWS

  • R and L Thorax: 2nd-3rd rib space, parasternal - pleural sliding clip or m mode of pleura still image
  • RUQ: Morison's pouch, paracolic gutter, diaphragm and spine
  • LUQ: focus on spleen, diaphragm and spine
  • Pelvis: trans and long: imaging posterior and lateral to bladder
  • subxyphoid: clip of heart imaging the pericardial space, IVC 

ED ECHO

Emergency bedside echo is one of the most useful skills during a resuscitation. It allows you to rapidly rule in or exclude major reversible causes of cardiovascular deterioration. Despite the initially daunting steep learning curve, most people are able to master the skills to gain adequate imaging in 3-6 months.

MACHINE AND PATIENT SETTINGS

  • Phased array transducer
  • cardiac setting
  • Patient supine or L lateral decubitus 

MINIMUM VIEWS

  • PLAx: L parasternal 3-4th rib space, probe marker R shoulder
  • PSAx: rotate 90 degrees on the best PLAx image (probe marker L shoulder)
  • A4C: at apex (usually anterior axillary line 5-6th rib space, probe marker at 3 o'clock
  • Subxyphoid: subxyphoid space angling anteriorly and to the left, probe marker to 3 o'clock
  • IVC: rotate 90 degrees on the subxyphoid view and angle towards the liver

Standard echo minimum views

LUNG

Lung US beats squinting at the CXR any day. It is as sensitive and accurate as CT chest and takes minimal time to learn.

MACHINE AND PATIENT SETTINGS

  • Curvilinear transducer
  • Abdominal setting (lung setting if looking specifically for pleural sliding or B lines)
  • Transducer perpendicular to chest wall, probe marker cranial
  • Patient supine (esp for pneumothorax) or upright)

MINIMUM VIEWS

  • R1 and L1: R and L MCL, above nipple line
  • R2 and L2: R and L MCL, below nipple line
  • R3 and L3: R and L MAL, above nipple line
  • R4 and L4: R and L MAL, below nipple line: superficial view for pleura, deep view for spine sign
  • Consider posterior imaging if abnormalities seen in R4 and L4

    Standard lung US minimum views

    Abdominal Aorta

    Abdominal US for assessment of the abdominal aorta is one of the oldest indications for ED US. It allows rapid diagnosis and expedited management of one of the most lethal and sometimes tricky ED presentations: AAA. 

    MACHINE AND PATIENT SETTINGS

    • Curvilinear transducer
    • Abdominal setting
    • Epigastric to umbilicus, transverse (probe marker to patient's right) and long (probe marker cranial)
    • Continuous downward pressure

    MINIMUM VIEWS

    • Epigastric aorta trans: may see coeliac trunk or SMA 
    • Mid aorta trans
    • Distal aorta trans
    • Iliacs trans
    • Aorta long

    Standard aorta minimum views

    DVT

    DVT US allows you to exclude or rule in an above knee DVT: enabling bedside management and rapid disposition.

    MACHINE AND PATIENT SETTINGS

    • Curvilinear transducer
    • Abdominal setting
    • Patients leg abducted and slightly flexed at hip and knee, reverse trendelenberg
    • Transverse, probe marker to patient's R
    • Decrease depth to have veins in the centre of the screen

    MINIMUM VIEWS

    • Common femoral vein trans: image with and without compression
    • Femoral vein trans: image with and without compression
    • Popliteal vein: image with and without compression
    • Pulse wave doppler of the CFV for respiratory variation

    Standard lower limb venous examination for DVT minimum views

    RENAL US FOR HYDRONEPHROSIS

    Hydronephrosis is easy to detect on ED US and easy to learn especially with our experience with EFAST. For the recurrent presenter with renal colic, it may obviate the need for repeated CT.

    MACHINE AND PATIENT SETTINGS

    • Curvilinear transducer
    • Abdominal setting
    • R and L upper quadrant angling towards the spine, probe marker cranial 
    • Patient supine or lateral decubitus

    MINIMUM VIEWS

    • R and L kidney long 2D
    • R and L kidney long with colour doppler for vascularity
    • R and L kidney trans
    • Bladder trans and long
    • Bladder trigone in trans or long (may apply colour for ureteral jets)

    Standard renal US for hydronephrosis minimum view

    GB US

    Finding cholelithiasis and a sonographic Murphey's means a diagnosis of acute cholecystitis is very likely, taking the guesswork out of RUQ abdominal pain and expediting disposition without waiting for WCC and the trajectory of pain. 

    MACHINE AND PATIENT SETTINGS

    • Curvilinear transducer
    • Abdominal setting
    • R subcostal, probe marker cranial
    • Patient supine or L lateral decubitus

    MINIMUM VIEWS

    • Gall bladder long (exclamation mark)
    • Gall bladder trans (measure anterior wall)
    • Porta hepatis with colour to identify CBD diameter 

    Standard GB US for cholecystitis minimum views

    OCULAR US

    Sick of not seeing the optic disc with the ophthalmoscope? Can't get that close to the patient due to COVID? Why not use US... (but make sure you use the ophthalmic setting)

    MACHINE AND PATIENT SETTINGS

    • Linear transducer
    • Ophthalmic setting
    • Tegaderm over the patient's closed eye
    • Thick layer of gel

    MINIMUM VIEWS

    • Orbit in trans and long imaged with eye movements in all directions 
    • Femoral vein trans: image with and without compression
    • Popliteal vein: image with and without compression
    • Pulse wave doppler of the CFV for respiratory variation

    Standed ocular US minimum views

    SCROTAL US

    Never let your US delay a call to theatre and urology for a torsion presentation. A normal looking testicle with normal colour doppler and pulsed doppler flow may have torted and de-torted. An absence of flow and evidence of ischaemia (heterogenic echotexture) increases the urgency of definitive management.

    MACHINE AND PATIENT SETTINGS

    • Linear transducer
    • Scrotal setting
    • Consider a chaperone
    • Elevate scrotum on a towel 

    MINIMUM VIEWS

    • R and L testicle long and trans
    • Colour doppler comparing R and L
    • Pulsed doppler of the affected side for flow pattern
    • Trans and long of epididymus
    • Colour doppler comparing L and R epididymus

    Standard testicular US for vascularity minimum views

    EARLY PREGNANCY US

    The point of early pregnancy US in the patient with pelvic pain or PV bleeding is to identify an IUP, assess for foetal HR and to look at the adnexa for a mass and the peritoneum for free fluid. Remember that 1/30000 pregnancies may be heterotopic (higher for assisted pregnancies).

    MACHINE AND PATIENT SETTINGS

    • Curvilinear transducer
    • Abdominal setting

    MINIMUM VIEWS

    • Uterus long imaging endometrial cavity
    • If IUP present measure CRL and HR on M mode
    • Assess adnexa and pelvis for free fluid
    • Image R and L ovary, colour doppler on each ovary
    • Image RUQ: Morison's pouch and paracolic gutter for free fluid

    Standard US for early pregnancy US minimum views